The need for healthcare quality improvement is little disputed, yet considerable debate continues on how to measure and achieve quality improvement. One salient issue pertains to the use of exclusions (also called exceptions) in physician performance measures: the removal of patients from the denominator (and numerator) of the measure when these patients, for some valid reason, should not be included in the calculation of performance. Physician groups suggest that exclusions help to align the intent of the measures with the need of physicians to exercise clinical judgment and to include consideration of patient preferences. Representatives of health plans and employers have concerns about the accuracy of data for identifying exclusions and potential "loopholes" for gaming. Performance measure developers and vendors of electronic health record systems (EHRS) must balance attainment of higher accuracy against the cost and complexity of gathering data. Resolution of the concerns over exclusions is predicated on empirical understanding of the prevalence and patterns of exclusions in national physician performance measurement, which is currently lacking. [unreadable] [unreadable] We propose a 2-year observational study of exception reporting, building on our prior work under Cardio-HIT, a research collaborative of 5 EHRS-enabled independent group practices that have been collecting data and reporting on nationally recognized physician performance measures for coronary artery disease and heart failure. In our proposed Cardio-HIT Phase II project we will: (1) empirically document the prevalence and patterns of exception reporting in these measures; (2) assess the feasibility and accuracy of exception reporting by validating a sample of reported exceptions against [unreadable] manual EHRS record review; and (3) analyze and address stakeholder concerns regarding exception reporting to refine existing principles in the design of physician performance measures. Partnering with the 5 practice sites are experts from the American Medical Association, convener of the Physician Consortium for Performance Improvement; the National Committee on Quality Assurance; the Iowa Foundation for Medical Care; and First Consulting Group. [unreadable] [unreadable] [unreadable] [unreadable]